Multitechnique approach for peri-mitral flutter: A case report of combining direct vein of Marshall ethanol infusion and alpha loop ablation

The management of peri-mitral flutter often necessitates a vein of Marshall (VOM) ethanol infusion (EI) and radiofrequency ablation within the coronary sinus (CS). These procedures can be technically demanding due to the anatomical constraints and require a nuanced understanding of catheter techniques. We report a patient who experienced dual tachycardias involving a peri-mitral flutter and roof-dependent atrial tachycardia after cryoballoon pulmonary vein isolation. Since linear ablation of the lateral mitral isthmus failed to eliminate the tachycardia, the involvement of epicardial structures such as the VOM and CS was suggested. Attempts at a VOM-EI using a catheter with a lumen succeeded in delivering ethanol but failed to terminate the arrhythmia. Standard techniques for catheter insertion into the CS were unsuccessful. By employing an alpha loop catheter configuration via the right femoral vein, a successful catheter insertion was achieved, enabling the ablation and immediate termination of the tachycardia. This case underscores the importance of employing innovative techniques, such as the alpha loop method and the direct VOM-EI via small-lumen catheters, in cases where standard approaches are insufficient. These methods provide viable alternatives for achieving successful outcomes in peri-mitral flutter management, especially when epicardial connections complicate the procedure. Learning objective: When standard catheter insertion into the coronary sinus is unsuccessful via the femoral vein, employing an alpha loop configuration can be an effective alternative. Direct ethanol infusion through a catheter with an inner lumen, rather than using over-the-wire balloon techniques, can be a viable option for a vein of Marshall ethanol infusion in anatomically challenging cases.